Provider Demographics
NPI:1558420778
Name:GEORGIA VASCULAR SPECIALISTS PC
Entity Type:Organization
Organization Name:GEORGIA VASCULAR SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAVERNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:POINDEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MBA
Authorized Official - Phone:404-350-9505
Mailing Address - Street 1:PO BOX 54888
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-0888
Mailing Address - Country:US
Mailing Address - Phone:404-350-9505
Mailing Address - Fax:404-350-1611
Practice Address - Street 1:1718 PEACHTREE ST NW
Practice Address - Street 2:SUITE 360
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2452
Practice Address - Country:US
Practice Address - Phone:404-350-9505
Practice Address - Fax:404-350-1611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA VASCULAR HOLDING CORPORATION PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7656Medicare ID - Type Unspecified